Objective: To assess the influence of the water fluoride level on periodontal status, by determining the periodontal health status of subjects residing in low, optimum and high fluoride areas. Study design: A cross sectional survey was carried out on 967 adults aged 35-44 years old, from the Udaipur district of India. A stratified cluster random sampling technique was implemented in order to collect a representative sample from low (<0.6 ppm), optimum (0.6 - 1.2 ppm) and high fluoride (>3ppm) areas, based on the fluoride concentration in drinking water. Periodontal status was assessed in accordance to WHO criteria. The Chi-square test was used to compare proportions, and logistic regression analysis was used to determine the contribution of water fluoride levels to periodontal disease. Results: Those residing in areas of low fluoride levels were more likely to present periodontal pockets than those living in high fluoride areas 1.3 (95 % CI 1.11±1.86). Subjects living in areas of low fluoride were noted to have a higher risk of periodontal attachment loss of more than 8mm (OR = 1.94, 95% CI 1.67±3.85). The risk for presence of periodontal pockets and attachment loss of more than 8mm increased by 1.17 (95 % CI 1.02±1.69) and 1.59 (95 % CI 1.27±3.29) respectively for those residing in areas of optimum fluoride levels. Deep periodontal pockets were more prevalent (6.3%) among those residing in areas of low fluoride, followed by optimum (5.2%) and high (3.1%). Conclusions: As the fluoride concentrations increased, the prevalence of shallow and deep periodontal pockets decreased. The severity of periodontal disease was significantly associated with fluoride levels, with cases of loss of attachment gradually decreasing when moving from low fluoride areas to high fluoride areas. It appears that longitudinal studies need to be conducted in order to ascertain the benefits; and microbiological analysis of dental plaque and periodontium should be carried out in order to confirm the effects of fluoride on periodontal conditions.